Whilst biomedical models of health and illness have
undoubtedly improved health through medical interventions
and treatments they are limited in what they
can say about embodied experiences of illness. One
common theme being promoted at the moment is
patient centredness which purports to focus health
care and research on what matters to patients about
their health needs. Patient centredness helps us to
understand the social determinants of health care,[1]
and it is argued that this knowledge and direction will
help illuminate some of the facilitators and barriers
that characterise the often disembodied research and
healthcare provision for patients.

Embodied health research represents the perceptual
system – the intuitions and institutions and structural
constraints that underlie patients’ ability to negotiate
and move through the complex maze of health information
and perform activities and interactions with
others in our environment that promote good health,
or at least attempt to lessen the risks associated with ill
health. Embodiment also encompasses howwe understand
the world and our relationship to it through our
positionalities, affected through our identifications with
gender, ethnicity, sexuality, class, nationality, religion,
age and so on. We can assume then that all embodied
human practices, including those related to health,
illness and primary health care are interdependent and
intersecting practices. Both embodied and material
biomedical processes affect how patients are differently
inculcated in primary healthcare systems in continuously
renegotiated ways. However, the biomedical
approach and embodied approaches to the study of
health and illnesses of diverse populations have developed
in ways relatively isolated from one another.

To this end, there is a growing interest in intersectionality
theory[2–4] as a process of clinical and health
service enquiry and as a research approach that explores
the complexity of multiple embodied social relations
that ultimately impact disparately on people’s health.
Long before health researchers began speaking of multiple
embodiments, intersectionality theory[5] originated
in black feminist critique of Western second wave
feminism. Western feminism was rightly accused of disregarding or downplaying differences of race, class
and sexuality and treating multiple differences as the
sum of distinct individual oppression.[3] This wave of
feminist critique argued against any notion that a
singular oppression, i.e. patriarchy, can be considered
more important than others, such as racism or homophobia,
or that oppressions can be hierarchically situated
universally through time.[6]What the critique also illustrates
is that relations of power cannot be seen as
simple additive and quantifiable factors, each having
equal impact in somebody’s life, a positivistic dilemma
inmany biomedical models of illness, due to the research
having to ignore, exclude or circumventmuchembodied
knowledge in order to produce invariant empirically
based findings. Relational identifications are always
overlapping, intersecting and variant in ways that make
it impossible to view each variable as separate ‘pure’
causalities – in our case, of receiving and accessing
primary health care. Therefore, where intersectionality
theory considers the formation of genders, I think it is
safe to say that we all have a sense of ‘one’ even though
‘it’ is constantly interpreted as a positionality, through
differential patterns of vulnerability, needs and commitments
to health and wellbeing and reinterpreted
and adapted to according to ephemeral cultural and
environmental situations.

The study of persistent patterns of health disparities
and how to eliminate these has become a major priority
for national health services, politicians, health
advocates, researchers and patients themselves.[4] It is
therefore all the more surprising that in primary care
intersectionality theory is still in its infancy, even
though proponents of this method of inquiry describe
major benefits, which include being able to incorporate
more patient-centred dimensions that foster situationally
specific interpretations[7] and group and interrelational
dynamics, and provide an explicit emphasis on social
and institutional change[4] that looks beyond simplistic
demographics and medical conditions.[8] These are
mantras often heard from primary care practitioners
in relation to the complex work and the heterogeneity
of patient populations and their diverse responses to
medical interventions.

Whilst feminist healthcare researchers are more
attuned to critiquing and challenging the assumed
universal generalisability of primary healthcare research
findings and approaches to practice,[9] they too have had
difficulty in building the capacity to develop understandings
about the multiple axes of identity and power
relations that characterise patients in society, and
which affect their health disparately. This work continues
to be overshadowed by the standard work on
singular axes that look at, for instance, ‘class’ as the
primary aspect or ‘gender’ as a singular axis of health
disparities. At best, when class and gender are combined
to explore various healthcare issues,[10] they
minimise their scope by skating over or just ignoring
more complex aspects of gendered power relations,
gender relationships and other salient cultural relationships
and how these may intersect with the multiplicity
of axes that are implicated within each and
everybody’s life.

In response to the challenges above, some research
seeks to counteract one- and two-dimensional approaches
by bringing to light the complexity of social
locations and experiences for understanding differences
in health needs and outcomes.[11] Within this
paradigm the multiple axes that people identify with
in society intersect with various intensities to affect
access, presentation to practitioners, treatment choices
and treatment in primary care. This moves the debate
towards the structural aspects of social life, and structural
aspects within the surgery, whilst retaining a
focus on salient identifications that patients make in
their lives as much as the particular illness that is being
presented. Intersectionality theory ‘provides a powerful
alternative way of addressing questions about health
access, presentation and treatment (choice) disparities
that traditional approaches have been unsuccessful in
answering’ (p. 222).4 Despite this there has been little
dialogue about how intersectionality is researched in
practice, without the project becoming too cumbersome.

There are a few notable exceptions in primary care
research. The intersectionality approach has been used
to describe how primary health care can inform policy
to improve the social determinants of child mental
health.[12] McGibbon and McPherson13 combine intersectionality
theory, complexity theory and the social
determinants of health approaches to illustrate the
individual’s experience and then extrapolate to the
broader social location embodied by an individual,
which contributes to understandings about healthcare
access and practices in the area of women’s health
inequities. What is interesting in this work is their
application of geographical aspects of location and
distance as other confounding factors of structural
relations, which synergises with axes of identifications
and identity markers to produce health inequities. For
instance, immigrant women are usually in lower paid, part-time, precariously safeguarded work, often a
great distance away fromfriendship and kin networks;
this, joined with racism and poor housing, results in
unfavourable social conditions, all of which can add
associated bodily stresses thatmay exacerbate ill health.[13]
Cole and Foster[14] argue that hazardous waste facilities,
landfill sites and incinerators are all disproportionately
located near communities of colour or housing for the
poor generally, producing increased risks to health.
Insights into these social location aspects could be
adapted and incorporated into research design and
practice capacities to add depth and complexity to our
understanding of health and illness and health care
and perhaps provide more patient-centred care.

Perhaps one of the most important steps to consider
in patient-centred primary health care, when thinking
through intersectionality research, is how clinicians
interact and intersect with patients. Primary healthcare
practitioners are often unmarked and constantly
evade problematisation when researching health care
(disparities). Practitioners are intentional beings with
intersecting identities working in institutions affected
by hierarchies of power, gender, sexuality and other
social relations and working with hierarchies of illness
and disease.[15] The ‘facelessness’ of healthcare providers
in both research and practice must be exposed in
future in order to ground more complex additions
to our knowledge base and transference of knowledge.
With a focus on the intersections of primary healthcare
providers, and the axes that interconnect to patients,
we may contribute to the study of patient centredness
as an intersectional set of embodied processes in space
and through time.

References

Syme SL. Reducing racial and social-class inequalities in health: the need for a new approach. Health Affairs 2008;27:456–9.

Bekker MHJ. Investigating gender within health research is more than sex disaggregation of data: a multi-fact gender and health model. Psychology, Health and Medicine 2003;8:231–43.

Barr HL, Britton J, Smyth A and Fogarty AW. Association between socioeconomic status, sex, and age at death from cystic fibrosis in England and Wales (1959 to 2008): cross sectional study. BMJ 2011;343:d4662.

Hankivsky O and Cormier R. Intersectionality and public policy: some lessons from existing models. Political Research Quarterly 2011;64:217–29.

McPherson C and McGibbon E. Addressing the determinants of child mental health: intersectionality as a guide to primary health care renewal. Canadian Journal of Nursing Research 2010;42:50–64.

McGibbon E and McPherson C. Applying intersectionality and complexity theory to address the social determinants of women’s health. Women’s Health and Urban Life 2011;10:59–86.

Cole L and Foster S. From the Ground Up: environmental racism and the rise of the environmental justice movement. New York, NY: New York University Press, 2000.

Album D and Westin S. Do diseases have a prestige hierarchy? A survey among physicians and medical students. Social Science and Medicine 2008;66:182–8.

Select your language of interest to view the total content in your interested language